Why B.H.A.G.s without B.H.A.R.s are Pipe Dreams

by Burl Stamp

Part 5 in our Series: A Smarter Approach to S.M.A.R.T. Goals

“I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the Earth.”

That quote from President John F. Kennedy’s speech to a joint session of Congress on May 25, 1961, is perhaps the most often cited example of the philosophy that when you set big goals, amazing things can happen. And who doesn’t want to accomplish amazing things.

So the fact that the “R” in our smarter S.M.A.R.T. goals model stands for “realistic” may be surprising. Realistic sounds so safe … hum-drum … even boring. Don’t we want bigger, transformative, inspiring goals? Maybe even “B.H.A.G.s”?

Even if you haven’t read one of the best-selling business books of the past 50 years, Built to Last by Jim Collins and Jerry Porras, you’ve probably heard about “big, hairy, audacious goals,” or B.H.A.G.s. And the first example of a B.H.A.G. that Collins and Porras cited in their explanation of this concept was President Kennedy’s bold man-on-the-moon goal.

Does our suggestion that goals should be realistic mean that we believe B.H.A.G.s aren’t useful, or even worse, simply pipe dreams? Not at all. It simply means that to be realistic, B.H.A.G.s require B.H.A.R.s – big, hairy, audacious resources.

What Makes a Goal Realistic – or Unrealistic?

While everyone remembers the man-on-the-moon ambition in President Kennedy’s speech to Congress, the sentence immediately preceding that statement arguably was just as important:

“I therefore ask the Congress, above and beyond the increases I have earlier requested for space activities, to provide the funds which are needed to meet the following national goals….”

No goal, in and of itself, is either realistic or unrealistic. The determinant of whether it is realistic is answered almost entirely by one question: Can and will we devote sufficient resources to achieving the goal?

Kennedy’s audacious moon landing goal dramatically illustrates this point. His bold challenge to put a man on the moon was both aspirational and inspirational. Its primary purpose was to rally the support of the American people and more importantly the Congress to fund the goal’s achievement. Remember that the space program at the time was a matter of national pride. We had to beat the Russians, and we were behind in the early 1960s.

The accompanying graph illustrates how significantly resources often have to be redirected to achieve a B.H.A.G.  NASA’s annual budget in 1961 when Kennedy made his bold proclamation was $744 million. By 1966 at its peak, the annual NASA budget had reached $5.9 billion, an increase of nearly 700%. As the line graph shows, the increase in the share of total federal spending for NASA in the 1960s was even more dramatic and illustrates another important point: effective planning and goal-setting is about prioritization. Resources are not unlimited so focusing time and spending in one area usually means sacrifices in others.

Realistic Resources

Setting realistic goals in patient experience improvement is especially susceptible to the problem of under-resourcing. Everyone wants to be at the 75th percentile rank (at a minimum) on H-CAHPS scores, but being better than three-quarters of the other hospitals in the country takes a significant commitment if you are starting at or below the median. Over the years, I’ve encountered more than one well-intentioned health system who set an inspirational goal of being at the 99th percentile without allocating sufficient resources to get there. I remember talking with one dedicated, experienced staff nurse who quietly admitted, “We’ve all just reached a point where we ignore that. We all work very hard, and we know achieving that is impossible. If we take it seriously, it is too demoralizing year after year when we don’t achieve it.”

In summary, following are several tips for setting aggressive but realistic goals that are achievable:

Recognize that not every goal can be a B.H.A.G.

Stretch goals are fine, but not every goal in every area can be a stretch. Setting aggressive goals in a few areas and devoting adequate resources to achieving them is better than spreading resources too thinly.

A stretch for one unit may be a cake-walk for another

Organization-wide goals for quality, safety or service metrics are reasonable, but they often need to be analyzed and adjusted to be realistic for individual units. This is especially true for patient experience goals. It is fine to set a goal of reaching the 75th percentile rank for a unit that has been at the 60th percentile. But for another unit at the 25th percentile with a more challenging patient population, that goal in a single year would be extremely difficult.

Industry data can help determine realistic goals

In some areas, using industry benchmark data can help teams assess just how challenging the achievement of a goal will be. For example, Press Ganey and other patient satisfaction survey companies can tell you how many hospitals, on average, were able to move performance by specific amounts depending on their starting points.

Linking the allocation of resources to the achievement of stretch goals is essential. Well-intentioned “inspirational” goals quickly become disheartening for teams that are hampered by too few resources to achieve them.

Stamp & Chase offers unexpected solutions to universal challenges facing leading healthcare organizations. To learn more about our robust tools and approaches that help healthcare leaders transform patient and staff engagement, visit Stamp & Chase.

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